Section B: To the patient: Please read the following statements carefully
Purpose of Consent: By signing this form, you will consent our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practice: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make for you protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our policy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including and revision of our notice, at any time by contacting: (305) 477-5299.
Consent of Communication: I give full consent to the doctor and his staff to contact me via, phone call, text message, email, correspondence, or any other media to contact me, they are authorized to leave messages on voice mail or in person, appointment reminders, postcards, letters, statements, or other methods, in reference to any items that assist the practice in carrying out treatment, payment activities and healthcare operations.
Signature: By signing this form, I have had full opportunity to read and consider the consents of this consent form and your Notice of Privacy Practices, I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.